0003-108 (RER)LICENSED CONTRACTOR DECLARATION.
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Pfotessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
97 9 B I e 44Dc
DJ7
ate L
Signature of Contractor = rF;�naf
OWNER -BUILDER DE RAI 1/0
I hereby affirm under penalty of perjury that I am exempt from the Contractors
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as'their sole -
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section . B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation,, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(_)- I have and will maintain workers'- compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My 'workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. 229-97 0018193
(This section need not be`completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit.is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
/subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those'povisions.
Date:"? Applicant V
Warning: Failure to secure Wor rs' Compen`ation coverage is unlawful and
shall subject an -employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees. to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application .becomes null and void if
work is not commenced within 180 days from date' of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that 1 -have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction; and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspection purposes.
/S ignature (Owner/Agent) ��--Date�L
C'
BUILDING PERMIT PERMIT J/
t
DACT, E VALUATION ; LOT :. 0003408 TRACT
r
JOB'SITE
ADDRESS .5R-172 A.VEN7C A Vhj4LEJO}
OWNER CONTRACTOR/DESIGNER/ENGINEER
RTC'HARD CR.00� r.17 M L 14AR CONSTR 7kMON & R MODI tL t(
51-177 AV MW �ZI,60 ?702_ CA1,1 '?RiJYADR !
L.AQUINTA '.` CA, 92253 PAL 1ft'IERT CA 92211 3
060)345-9564 CB110 4790
t
USE OF PERMIT PA f
RE3WM4TLkL UMODEL APA
'n
ADD TRUSS ROOF WITH TILE, TO MIST11dO STRUCTURE ^J9ZU00.
VALUATION' 2 000.00 L�
4
ESTIMATED COST O CON UCVOPi
t?.OiYJ
PERMIT FEE SUT*IARY
PIAN CHECK FEE 101-000-439-318 5134.55
CONSTRUCTION PEE 101-000-418-000 $207.00
MECHANICAT, FEE 101.000-421.000 137,30
ELECTRICAL FEE 101-000-420-000 $34.35.
STR.ONO MOTION FEE - RESiD 101-000-241.000 52,00
3[113 -TOTAL CONS rRUC IJOAT AND PLM CHECK
$413.30.
LESS PRE -PAID Fri
$0.00
x'41' AL PERMIT 17 YS DUE NOW
S415.'.40
�t
RECEIPT
DATE
/b
DATE INALE `
INSPECTOR
!
// r
L - OV)
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
` BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
464
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
-
Compressor _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-�
Drywall - Int. Lath
Final
Final z db
BLOCKWALL AP ROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
—Cf��3b g-7
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
T
y1
4
. . . . . . . . . .
16V U Quints
B.in.
Building K'Sdery Divisipn�
p;0. Box 1-504
78-495 Calle Tampico
a nta CA 92253,
L ul �'
Q
'd4'Tr .'
Permit Application, an .- acking Sheev.
136ilding P6
Project
"er's Name
A�ldress:'
-7- I
n
'Address: a
A. P. Number: ZT
I'Descri
L;ya ption:
7/,,
7 P.,
j
Contractor: IV
Telephone:,
A . ss:
ddre
Project Des m- Uon:
A
7hy'
Cir%�.ST. Zip:
Tel !phoAe:
.......... .
I r
State 9/
St
rv.Lic #:
Ci " -
10,
ti
ZAG"""/
A: rch..Imzr_Desig ner:
City. ST. Zip-'�' "I
44
T L; u an
Constructio U ype:
Telephone:
'Add'n Al
;Sr •I�epaiir . Detno
"ea type (circle one New
P r0i
State Lic
Name Coltact Person:
r
�q! R.-
9 Sidri es:
ts,
'of
V5
'tstnitedValue -'OfProject:
Telep'hone,Conta erson, -
............
.. . ..... .....
......... .
..............
PPP ...............................
-N 'i -WIN
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Plan am
Structuf...";
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7
PETITION'FOR THE ANNEXATION OF CERTAIN LAND TO
IMPROVEMENT.DISTRICT NO.--. 55
AND REQUEST - FOR SANITATION SERVICE
OF COACHELLA VALLEY WATER DISTRICT
Petitioner alleges: F '
(1) That it is the, owner of certain land in the County of Riverside, State'of .,
`California, 'described as: „ �r
'.Tract (Name or Number). Blo k % Lot
Record of•Survey: Book Page Map 'Book: Book Page_ q Lot
Legal Description Sec. T- S, R E
Street Aaaress - d- vrN I -W11
rT
- -
Assessor ; s Number 71;0(o
(2) That it.hereby petitions, requests and consents to the annexation of such
land to,Improvement District No -.55 of the Coachella Valley Water. District.
(3) That i* ^4�-ar=nAg that'the conditions of such annexation are:
rict No: 55 shall be .
(a) T:
nt.District' and shall
S, i».
subject to the existini
likewise - ,be subject to' levied-witliin'such ..
Improvement District. R O s'E N O W S•P E V A,C'E H G R O-.0 P I N C:"
!714 '541-4585 Far 7.14-836•-1748 `
(b) T; G rict No. 5:5- shall.be
.✓ ,
subject to the payment amounts set; out in
District' Rules and Reg f 'his petition.'
_ ter District may
(4) that't / �t.tt%L;
proceed -with such anne, +, eof,without further
/
notice to petitioner.
(5) The un /� p to all regulations
�1=�=�`-=-'� vice charge which
of the Coachella Valle L '_ fes,
shail' begin when a dis�`Q Qr`-,G'" W0.Se j}�-pk ,d -�p SP�eN-
\j--if-1
h
any
Any failure to`comply with
- receding�anne tion c dations;may cause the
district to terminate` all' district services provided the"land be ng'annexed in•
(Type or Print). -
�,�
Date
Name -of -Petitioner _ g tur of Petitioner.
, Date
Mailing Address Y�/Signature of Petitioner
'Date
Telho,ne r Signature of Petitioner
(v� S�o 7— v�(�
THIS DOCUMENT REQUIRES THE SIGNATURES OF ALL OWNERS OF THE ABOVE-DESCRIBED'PROPERTY.
(FOR DISTRICT USE ONLY) '
Account No. MCR No. Date Class EDUs
CVWD-2030
(Rev.. 7/99)
General Environmental
Man nyentServices •— Environmental Tc-stina and Consultingr
January 24, 2000 „ • `"
Richard Crocket
P:'O. Box'1440
La Quinta, CA 92253
Re: Inspection for asbestos containing materials (acm) at;
1. 51172 Ave. ,Vallejo, La Quinta, Ca. — roof and addition
k
On January 21, 2000 General Environmental Managemdht'Services'(GEM Serviecs)�' . - '
conducted an inspection at the'above'referenced location to confifm or deny the presence
of asbestos containing materials (ACM) in specific areas of the structure at that location. r;
Tlae stricture can be described as follows; a single-family residence with an attached'
addition at the .rear of the structure. The scope of the inspection included the entire 'roof
and the addition.- The inspection was tequested.due to a planned re -roofing project and i
the demolition of the addition. "
Our. inspection revealed that several suspect arm were located in various areas of the
structure. The following TABLE 1. represents those materials that Were suspected of
containing asbestos as well as the areas in which they were located.
TAB
BL� 1
•" Drywall and joint compound — ceiling at section of addition ;
•
'Roof felts — roof over main house .
• Roofing, cap sheet • roof over addition
•'y Roofing mastic - roof at fiches and penetrations (assumed to contain asbestos, no
samples)
Sahipless-were collected of each dithese materials and subsequently subraiL ed -.to the �.
laboratory for analysis by Polarized Light Microscopy (PLM) to detcrruine if asbestos ,
was present and if so, to determine the percent composition in which it was present"
Those materials containing greater than one tenth of one percent asbestos (0.1 %) are
considered asbestos containing construction inaterials (accm) as defined by the State of
California.. If materials containing greater than 0. l% asbestos are to be disturbed, the
work must be perfornned in compliance with the California Code of Regulations, 'Title 8,
Section 1529, (CaVOSHA Asbestos Standard for the Construction In i stry). '('hose -
materials containing greater than one percent (Pyo) asbestos are considered to be acm'by
the Environmental Protection Agency (EPA) and the 'South Coast Aix Quality .
,- Managerrient District (SCAQMD), If acm is to be damaged or disturbed during,
construction or demolition activities, they become subjiret to the requirements of the
EPA's National Emission Standard for Hazardous Air Pollutants (NESHAP`s) andfor
10970 Arrow Route, Suite 212, Rancho Cucamonga, CA. 91730 (800)886-2589
.£d ' Wd2Z:90 0002 t7T •a1ew, i 2_tiZ66t7£09Z '(]N Xdd Woad
i
Page 2; inspection report
SCAQM-D Rule 1403, Asbestos Emissions from Renovation and Demolition Activities.
The materials found to Contain asbestos in amounts of greater than D.1 % and%r 1% are
' listed in TABLE 2..,
TABLE 2
• Roofing mastic — roof at patches, and penetrations trations —15 sgft.
Our findings on this project were obtained using the generally accepted practices and J,•
procedures followed by the asbestos survey industry. The number of samples collgc4i _t ...
-, may not have been in ac
accordance, with the guidelines found in the,_AtQ1vVfations.~
The •inspection was conducted in;suh.., rmpliance with the provisions of 'the";,
AfJ's ul'e 1403. GEiN Services cannot be responsible for sub -surface or
inaccessible materials that may not have been identified during the survey although a
reasonable effort will be made to ascertain their presence. The quantities shown above for
those materials fouind to contain asbestos are approximate. Contractors bidding on -the
removal of acm or seem should use their own measurements. We recommend that any
asbestos removal be performed by a contractor trained and experienced inasbestosremoval operations and who is registered with the State of California's Division of
Occupational Safety and Health as well as being licensed with the Contiaetors State
Licensing Board for asbestos removal.
This wncludes our report, please call if we can'be of further assistance. We have
included a summary of the laboratory sample results and the credentials of the individual
that conducted the inspection,
Joseph Johnson
rtified Asbestos Consultant, #92-0698
GEM Services
10970 Arrow Route, Suite 212, Rancho Cucamonga, CA. 91730 (800) 886-2589
ed ' WdZZ:90 0002 bT 'aieW LT?_66b2092_ ON Xdj
General thvironmental
ManaaemenuServeces --Environmental Testing and Consultibg '
SUMMARY OF LARQRATOR YS"PLE RESULTS
The following list is a summary of the Laboratory results for the samples collected at.the
project location listed below. The samples were analyzed- using Polarized' Light y `
Microscopy (PLM) with dispersion Staining techniques by EMS Laboratory, 117-W.
Bellevue, Pasadena, Ca., EMS Laboratory is Accredited under the Natibm d Voluntary'
Laboratory -Accreditation Program (NVLAP) for conducting bulls asbestos analysis by
PLM. a.
moi! GEM Services Curt 1D N, FF07552D Analvsiv Date; O 1-24-00 Renort Dale; D 1-24-00
CUSTOMER; , Richard Cro&et PROJECT, 51-172 Ave. Vallejo �
P.O. Box,1440 La Quinta, CA '
La Quints. CA. 92253
SAMPLE. DESCRTMON LOCATION TOTAL t
NUMBER OF MAIMAL SAXPLED OF SAMPLE Asms?os coNTEN-r
I • . Roofing felts Roof over front porch ND
2- Drywall and joint compound Ceiling at seam in addition ND •
3- Cap sheet roofing Roof over.addition ND
r
REST CODES
CFI - Chrysotile CR _ Crocldolite AM - Amosite AN - A,nthophyllite TR - Tremolite
AC - Actinolite NI) - None Detected less than > greater than
.10970 Arrow Route„Suite 212, Rancho Cucamonga, CA. 91730 (800)886-2589:
bd WdZE:90 0002 bi •,A2W LTL66b209L T11 Xdd : WDad
,
Orgy Davis: cover1XV
SPAR i�IENT OF INDUSTRIAL RELATIONS '
5
DIVI"S�ON OF OCCUPATIONAL SAFETY AND HEAL
r:
ASBESTOS CONSULTANT CERTIFICATION UNIT
= ,� G �•
•
2211Pack Towne Cirde, Suite 1 '!
,
sacram nto, CA 95825
(916) 5742993 Fax (9y 6) 483-0572
2090906980 18 -
September 10, 1999
Joseph Johnson
General Environmental Management Services
;
10970 Arrow Route, #212
t
.Rancho Cucamonga CA-, 91730
Dear Certified Asbestos Consultant or Technician:'-
Enclosed is your certification card. To maintain your..certificatiora, please abide by the rules
printed on the back of the certification card.
Your certification is valid for a period of one year. if you wish
to renew your certification; 'you- must
apply for renewal at least 60•days pefore the expiration date; shown on your card. [8CCR
,341.15(h)(1)].
Please hold -and do not'send copies of your required AHERA refresher renewal certificates to the `
Division until you apply for renewal of your certiflOatiOn.
Please inform the Division of any changes in your mailing
address or work address within 15 days.
Sincerely, J
t
Rick Axes r
Senior industrial Hygienist.
RA/dor
Attachment card
Reminder Notice
State of California
Division of Occupational Safety and Health
'
Certified Asbestos Consultant
cc Filer ` - i '
Joseph Edward Johnson
passl 3196
Certification No. 92-0696
•
9/16/2000
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